Medicaid Expansion Increases Pap, Breast Exams

RWJF scholar’s study finds a greater share of low-income women are screened in states with expanded Medicaid family planning services.

When states made more low-income women eligible for Medicaid family planning services, a significantly higher percentage of those women obtained potentially lifesaving Pap tests and breast exams, according to a study by a Robert Wood Johnson Foundation (RWJF) Health & Society Scholar.

Scholar Laura Wherry, PhD (2012-2014), analyzed health survey data from states with and without expanded Medicaid family planning programs between 1993 and 2009, and examined changes in the services that eligible women used. Her study found that “expansions in Medicaid family planning services increased screenings for breast and cervical cancer among low-income women and narrowed the gap in the utilization of these services when compared with higher income women.”

Wherry’s findings take on added significance given changes in regulations governing state Medicaid expansions under the Affordable Care Act (ACA). During the period Wherry studied, states had to obtain federal waivers to extend Medicaid family planning services to women who were otherwise ineligible for Medicaid. But since passage of the ACA in 2010, Wherry says, administrative reforms “make it much easier for states to adopt these family planning programs, even if they’re not implementing the broader Medicaid expansion.”

An RWJF Health & Society Scholar at the University of Michigan School of Public Health, Wherry believes her study is “among the first to examine the impact of these expansions on the use of preventive health care.” The study, “Medicaid Family Planning Expansions and Related Preventive Care,” was published in the September 2013 issue of the American Journal of Public Health.

In her study, Wherry used health behavior information collected from reproductive-age women in a nationally representative survey. She looked at whether the women had had a Pap test, a clinical breast exam, or a routine doctor checkup in the past 12 months; whether they ever had been tested for HIV; and whether they had had a Pap test within the past three years (the recommended screening interval during that period). Wherry then used statistical models to estimate how expanding eligibility of the Medicaid family planning program had affected the probability that women would obtain any of those health services.

Among women considered eligible for the family planning expansion programs, the study found no significant change in routine checkups or HIV testing. But Wherry found that state Medicaid expansion programs did increase the proportion of low-income women getting a Pap test within the last year by 2.8 percentage points, and the proportion of low-income women getting a clinical breast exam within the last year by 1.6 percentage points.

When those increases were scaled by the pool of women who participated in the expansion programs, Wherry says, “the estimates imply a 19.0 percent increase in Pap test receipt and a 10.9 percent increase in clinical breast examination receipt within a 12-month period among new program enrollees.” Her study also found a 2.2 percentage point increase in the proportion of low-income women getting a Pap test within three years, which Wherry says would amount to “an implied increase of 14.9 percent among new enrollees.”

By increasing the probability that low-income women would get Pap tests and breast exams, the family planning expansion programs have begun to close the longstanding income gap between women who do and don’t get the screenings, Wherry says. Her study compared the Pap test and breast exam utilization estimates of the Medicaid-eligible women to the rates at which higher-income women obtain those exams. That analysis revealed that the expansion programs reduced the size of the gaps in utilization on all the exams: on breast exams in a 12-month period by one-tenth, on Pap tests in a 12-month period by one-quarter, and on Pap tests within a three-year period by more than one-third.

Currently, 31 states implement Medicaid family planning expansion programs. While the programs are “something that states have been adopting since the mid-1990s, there’s not a lot of information out there on them,” Wherry says. Her study’s findings, she adds, show that expanding these programs can “play an important role in providing access” to life-saving preventive care as well as contraception.

As an RWJF Health & Society Scholar, Wherry plans to continue her research on public health insurance, with a focus on how federal health care reform will affect low-income populations. Her study, “Medicaid Family Planning Expansions and Related Preventive Care,” was supported by the RWJF Health & Society Scholars program and an Agency for Healthcare Research and Quality T32 Predoctoral Training Grant in Health Services Research at the University of Chicago.